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Variant: 1 Pregnant female. Age 40 years or older. Breast cancer screening. Any risk.

Procedure	Appropriateness Category
Digital breast tomosynthesis screening	Usually Appropriate
Mammography screening	Usually Appropriate
US breast	May Be Appropriate
Mammography with IV contrast	Usually Not Appropriate
MRI breast without and with IV contrast	Usually Not Appropriate
MRI breast without and with IV contrast abbreviated	Usually Not Appropriate
MRI breast without IV contrast	Usually Not Appropriate
MRI breast without IV contrast abbreviated	Usually Not Appropriate
Sestamibi MBI	Usually Not Appropriate

Variant: 2 Pregnant female. Age less than 25 years. Breast cancer screening. Higher-than-average risk.

Procedure	Appropriateness Category
US breast	May Be Appropriate
Digital breast tomosynthesis screening	Usually Not Appropriate
Mammography screening	Usually Not Appropriate
Mammography with IV contrast	Usually Not Appropriate
MRI breast without and with IV contrast	Usually Not Appropriate
MRI breast without and with IV contrast abbreviated	Usually Not Appropriate
MRI breast without IV contrast	Usually Not Appropriate
MRI breast without IV contrast abbreviated	Usually Not Appropriate
Sestamibi MBI	Usually Not Appropriate

Variant: 3 Pregnant female. Age 25 years or older. Breast cancer screening. Higher-than-average risk.

Procedure	Appropriateness Category
Digital breast tomosynthesis screening	Usually Appropriate
Mammography screening	Usually Appropriate
US breast	May Be Appropriate
Mammography with IV contrast	Usually Not Appropriate
MRI breast without and with IV contrast	Usually Not Appropriate
MRI breast without and with IV contrast abbreviated	Usually Not Appropriate
MRI breast without IV contrast	Usually Not Appropriate
MRI breast without IV contrast abbreviated	Usually Not Appropriate
Sestamibi MBI	Usually Not Appropriate

Variant: 4 Pregnant female. Age less than 30 years. Focal pain or palpable breast mass. Initial imaging.

Procedure	Appropriateness Category
US breast	Usually Appropriate
Digital breast tomosynthesis diagnostic	Usually Not Appropriate
Mammography diagnostic	Usually Not Appropriate
Mammography with IV contrast	Usually Not Appropriate
MRI breast without and with IV contrast	Usually Not Appropriate
MRI breast without IV contrast	Usually Not Appropriate
Sestamibi MBI	Usually Not Appropriate

Variant: 5 Pregnant female. Age 30 years or older. Focal pain or palpable breast mass. Initial imaging.

Procedure	Appropriateness Category
US breast	Usually Appropriate
Digital breast tomosynthesis diagnostic	Usually Appropriate
Mammography diagnostic	Usually Appropriate
Mammography with IV contrast	Usually Not Appropriate
MRI breast without and with IV contrast	Usually Not Appropriate
MRI breast without IV contrast	Usually Not Appropriate
Sestamibi MBI	Usually Not Appropriate

Variant: 6 Pregnant female. Age less than 30 years. Clinically suspicious nipple discharge. Initial imaging.

Procedure	Appropriateness Category
US breast	Usually Appropriate
Digital breast tomosynthesis diagnostic	Usually Not Appropriate
Mammography diagnostic	Usually Not Appropriate
Mammography with IV contrast	Usually Not Appropriate
MRI breast without and with IV contrast	Usually Not Appropriate
MRI breast without IV contrast	Usually Not Appropriate
Sestamibi MBI	Usually Not Appropriate

Variant: 7 Pregnant female. Age 30 years or older. Clinically suspicious nipple discharge. Initial imaging.

Procedure	Appropriateness Category
US breast	Usually Appropriate
Digital breast tomosynthesis diagnostic	Usually Appropriate
Mammography diagnostic	Usually Appropriate
Mammography with IV contrast	Usually Not Appropriate
MRI breast without and with IV contrast	Usually Not Appropriate
MRI breast without IV contrast	Usually Not Appropriate
Sestamibi MBI	Usually Not Appropriate

Variant: 8 Pregnant female. Newly diagnosed breast cancer. Locoregional staging.

Procedure	Appropriateness Category
US axilla	Usually Appropriate
US breast	Usually Appropriate
Digital breast tomosynthesis diagnostic	Usually Appropriate
Mammography diagnostic	Usually Appropriate
Mammography with IV contrast	Usually Not Appropriate
MRI breast without and with IV contrast	Usually Not Appropriate
MRI breast without IV contrast	Usually Not Appropriate
Sestamibi MBI	Usually Not Appropriate

Variant: 9 Pregnant female. Breast infection or abscess suspected. Initial imaging.

Procedure	Appropriateness Category
US breast	Usually Appropriate
Digital breast tomosynthesis diagnostic	May Be Appropriate
Mammography diagnostic	May Be Appropriate
Mammography with IV contrast	Usually Not Appropriate
MRI breast without and with IV contrast	Usually Not Appropriate
MRI breast without IV contrast	Usually Not Appropriate
Sestamibi MBI	Usually Not Appropriate

Variant: 10 Pregnant female. Palpable breast mass. US findings are probably benign. Next imaging study.

Procedure	Appropriateness Category
US breast	Usually Appropriate
US axilla	Usually Not Appropriate
Digital breast tomosynthesis diagnostic	Usually Not Appropriate
Mammography diagnostic	Usually Not Appropriate
Mammography with IV contrast	Usually Not Appropriate
Image-guided core biopsy breast	Usually Not Appropriate
Image-guided fine needle aspiration breast	Usually Not Appropriate
MRI breast without and with IV contrast	Usually Not Appropriate
MRI breast without IV contrast	Usually Not Appropriate
Sestamibi MBI	Usually Not Appropriate

Variant: 11 Pregnant female. Palpable breast mass. US findings are suspicious or highly suggestive of malignancy. Next imaging study.

Procedure	Appropriateness Category
US axilla	Usually Appropriate
US breast	Usually Appropriate
Digital breast tomosynthesis diagnostic	Usually Appropriate
Mammography diagnostic	Usually Appropriate
Image-guided core biopsy breast	Usually Appropriate
Image-guided fine needle aspiration breast	May Be Appropriate
Mammography with IV contrast	Usually Not Appropriate
MRI breast without and with IV contrast	Usually Not Appropriate
MRI breast without IV contrast	Usually Not Appropriate
Sestamibi MBI	Usually Not Appropriate

Lonie R. Salkowski, MD, PhD, MS^a; Alana A. Lewin, MD^b; Susan P. Weinstein, MD^c; Stacey Bartell, MD^d; Meredith L. Birsner, MD^e; Virginia Borges, MD^f; Elizabeth H. Dibble, MD^g; Katerina Dodelzon, MD^h; Basak E. Dogan, MDⁱ; Claudia Kasales, MD, MHA^j; Jean M. Kunjummen, DO^k; Cherie M. Kuzmiak, DO^l; Andrea Merrill, MD^m; Chirag Parghi, MD, MBAⁿ; Lisa V. Paulis, MD^o; Richard E. Sharpe Jr., MD, MBA^p; Priscilla J. Slanetz, MD, MPH^q.

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please visit https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

The ACR acknowledges the limitations in applying inclusive language when citing research studies that predates the use of the current understanding of language inclusive of diversity in sex, intersex, gender, and gender-diverse people. The data variables regarding sex and gender used in the cited literature will not be changed. However, this guideline will use the terminology and definitions as proposed by the National Institutes of Health.

Appropriateness Category Name	Appropriateness Rating	Appropriateness Category Definition
Usually Appropriate	7, 8, or 9	The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.
May Be Appropriate	4, 5, or 6	The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.
May Be Appropriate (Disagreement)	5	The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.
Usually Not Appropriate	1, 2, or 3	The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.

Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an imaging procedure. Patients in the pediatric age group are at inherently higher risk from exposure, because of both organ sensitivity and longer life expectancy (relevant to the long latency that appears to accompany radiation exposure). For these reasons, the RRL dose estimate ranges for pediatric examinations are lower as compared with those specified for adults (see Table below). Additional information regarding radiation dose assessment for imaging examinations can be found in the ACR Appropriateness Criteria^® Radiation Dose Assessment Introduction document.

Relative Radiation Level Designations
Relative Radiation Level*	Adult Effective Dose Estimate Range	Pediatric Effective Dose Estimate Range
O	0 mSv	0 mSv
☢	<0.1 mSv	<0.03 mSv
☢☢	0.1-1 mSv	0.03-0.3 mSv
☢☢☢	1-10 mSv	0.3-3 mSv
☢☢☢☢	10-30 mSv	3-10 mSv
☢☢☢☢☢	30-100 mSv	10-30 mSv
*RRL assignments for some of the examinations cannot be made, because the actual patient doses in these procedures vary as a function of a number of factors (e.g., region of the body exposed to ionizing radiation, the imaging guidance that is used). The RRLs for these examinations are designated as “Varies.”

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The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination

Breast Imaging During Pregnancy